HomeMy WebLinkAboutInspection Report 2020 Mar 20 M(41
11' Commonwealth of Massachusetts eF/—k 1 p�� �, I �7 •
-_- IF Title 5 Official Inspection Form APR o 7 2020
C -. - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
t � HEALTH DEPT.
° 4 Marsh Point,Yarmouth Port, MA ,, ..
Property AddressI
o4/o7/26V PR-tOL TI) t _, #, ,
Kathleen Fargo 4 Marsh Point
Owner Owner's Name /f''01(4 1 Deer zottFW Q � t
information is every Yarmouth Port
required for eve MA 02675 3/20/2020
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. Inspector Information
filling out forms
on the computer, Joseph only the tab M Martins
key to move your Name of Inspector
cursor-do not Accu Sepcheck
use the return Company Name
key.
17 Northside Drive
mot� Company Address
. South Dennis MA 02660
City/Town State Zip Code
�, , l 508-385-5891 SI 147
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); I have personally inspected the sewage disposal system at the property address
listed above;the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ❑ Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ® Fails
ti,
4/1/2020 1111A Ad
ctor's Signat e Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time. This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
1
•
• Commonwealth of Massachusetts
11-&*- F Title 5 Official Inspection Form
_ = Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
t� 1/;)
4 Marsh Point, Yarmouth Port, MA
Property Address
Kathleen Fargo 4 Marsh Point
Owner Owner's Name
information is
Yarmouth Port MA 02675 3/20/2020
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
{
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
❑ I have not found any information which indicates that any of the failure ci -ria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria , evaluated are
indicated below.
Comments:
2) System Conditionally Passes:
❑ One or more system c•' ponents as described in the "Conditional Pass"section need be
replaced or repaire• he system, upon completion of the replacement or repair, as ••proved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following stat; ents. If"not
determined,"please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether,-tal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is i nent. System will pass
inspection if the existing tank is replaced with a complying septi i tan approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally soun•I l •t leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old i :� ailable.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
+s
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4 Marsh Point,Yarmouth Port, MA
Property Address
Kathleen Fargo 4 Marsh Point
Owner Owner's Name
{ information is Yarmouth Port MA 02675 3/20/2020
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distributio► •ox due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution bo . System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND ( • ain below):
❑ obstruction is removed ❑ Y ❑ N ❑ 1%0 (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N / ND (Explain below):
❑ The system required pumping more than 4 ti -s a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval •f the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ONO ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is equired by the Board of Health:
❑ Conditions exis hich require further evaluation by the Board of Health in order to determine if
the system is :iling to protect public health, safety or the environment.
a. Syste • will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
•
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
- - ' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4 Marsh Point,Yarmouth Port, MA
Property Address
Kathleen Fargo 4 Marsh Point
Owner Owner's Name
information is Yarmouth Port MA 02675 3/20/2020
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
El Cesspool or privy is within 50 feet of a surface water
El Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public he. ,
safety and environment:
O The system has a septic tank and soil absorption system (SAS) and the SAS ' within
100 feet of a surface water supply or tributary to a surface water supply.
O The system has a septic tank and SAS and the SAS is within a Zone 1 • a public water
supply.
O The system has a septic tank and SAS and the SAS is within 50 f::t of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less • .n 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, perforr r -d at a i certified laboratory, for fecal
coliform bacteria indicates absent and the pr:,-nce • am •: la nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other r% eria are triggered.A copy of the analysis must
be attached to this form.
(
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
i
a
•
c Commonwealth of Massachusetts
n,._ F Title 5 Official Inspection Form
. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
t,\ I
,.-; 4 Marsh Point,Yarmouth Port, MA
Property Address
Kathleen Fargo 4 Marsh Point
Owner Owner's Name
information is Yarmouth Port MA 02675 3/20/2020
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
® ❑ Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ Liquid depth in cesspool is less than 6" below invert or available volume is less
than '%day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped: .
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
O ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ►5 Any portion of a cesspool or privy is within 50 feet of a private water supply well.
O ►l Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
® ❑ The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must s• e a - ity with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each oft - . lowing, in addition to the
questions in Section C.4.
Yes No ,
41
0 0 the system is within 400 - of a su ifce drinking water supply
❑ ❑ the system is wi • 200 feet of a tributary to a surface drinking water supply
O 0 the syste • s located in a nitrogen sensitive area (Interim Wellhead Protection
Are- - PA) or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4 Marsh Point,Yarmouth Port, MA
Property Address
Kathleen Fargo 4 Marsh Point
Owner Owner's Name
information is
required for every Yarmouth Port MA 02675 3/20/2020
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes"to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section C.4 above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section C.4 shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes" or"no"for each of the following for all inspections:
Yes No
• 0 Pumping information was provided by the owner, occupant, or Board of Health
O Were any of the system components pumped out in the previous two weeks?
®
0 Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
• 0 Was the facility or dwelling inspected for signs of sewage back up?
®
0 Was the site inspected for signs of break ou
• ❑ Were all system components, a n the SAS, located on site?
0 Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
• c Commonwealth of Massachusetts
L-*V7- F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4 Marsh Point, Yarmouth Port, MA
• Property Address
Kathleen Fargo 4 Marsh Point
Owner Owner's Name
information is Yarmouth Port
required for every MA 02675 3/20/2020
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
440
Description:
SYSTEM CONSISTS OF ONE 1000 GALLON SEPTIC TANK, ONE DISTRIBUTION BOX AND
THREE 4'x8'FLOW DIFFUSORS with 2'OF STONE AROUND.
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes 4 No
Does residence have a water treatment unit? ❑ Yes // No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes 0 No
Seasonal use? ❑ Yes /1 No
Water meter readings, if available (last 2 years usage (gpd)): 227 GPD
Detail:
2019:_61,000G ; 2018:_105,000 G
Sump pump?
0 Yes ® No
Last date of occupancy: 3/20/2020
Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
S, Commonwealth of Massachusetts
®mP 'F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
! 4 Marsh Point,Yarmouth Port, MA
Property Address
Kathleen Fargo 4 Marsh Point
Owner Owner's Name
information is Yarmouth Port MA 02675 3/20/2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial FlowConditions:
C nditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gall. pe •ay(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ® No
Water treatment unit present? ❑ Yes ® No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes4 No
Non-sanitary waste discharged t' the Title 5 system? ❑ Yes /� No
Water meter readings, if ay. able:
Last date of occupanc Se: Date
Other(describe b- ow):
3. Pumping Records:
Source of information: 4/28/2016, 5/13/2014 PER YARMOUTH PUMPING
DATABASE: aca3.accela.com/yarmouth/
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
.=7,= =ir Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
*4
4 Marsh Point, Yarmouth Port, MA
Property Address
Kathleen Fargo 4 Marsh Point
Owner Owner's Name
information is Yarmouth Port MA 02675 3/20/2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Y (
4. Type of System:
Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
El Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
El Tight tank.Attach a copy of the DEP approval.
El Other(describe):
Approximate age of all components, date installed (if known) and source of information:
AGE:_27 YEARS . INSTALLED_6/2/1992_. SOURCE: HEALTH DEPARTMENT RECORDS
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: "2
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: >10
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
FLUSH TESTED.
t5insp.doc•rev.7/28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
• Commonwealth of Massachusetts
r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1\ II
4 Marsh Point, Yarmouth Port, MA
Property Address
Kathleen Fargo 4 Marsh Point
Owner Owner's Name
information is Yarmouth Port MA 02675 3/20/2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 1
feet
Material of construction:
® concrete ❑ metal El fiberglass El polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes El No
Dimensions: APP 8.5'X6'X5', 1000 GAL
4 "
Sludge depth: •—
Distance from top of sludge to bottom of outlet tee or baffle NO OUTLET TEE
2 "
Scum thickness
Distance from top of scum to top of outlet tee or baffle NO OUTLET TEE
Distance from bottom of scum to bottom of outlet tee or baffle NO OUTLET TEE
How were dimensions determined? CORETAKER
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
HAS CONCRETE INLET TEE IN GOOD CONDITION. MISSING OUTLET TEE. LIQUID LEVEL IS
AT OUTLET INVERT AT 48". NO EVIDENCE OF LEAKAGE.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal poral System•Page 10 of 18
• cam, Commonwealth of Massachusetts
Title 5 Official Inspection Form
f Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
11.1 11A
° 4 Marsh Point, Yarmouth Port, MA
Property Address
1 Kathleen Fargo 4 Marsh Point
Owner Owner's Name
information is Yarmouth Port MA 02675 3/20/2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: NO GREASE TRAP
feet
Material of construction:
El concrete El metal El fiberglass El polyeth -n- El other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or •: e
Distance from bottom of scum to bottom of •• let tee or baffle
Date of last pumping: Date
Comments(on pumping recomme••ations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet '• ert, evidence of leakage, etc.):
‘0/
8. Tight or Holding Tank (tank must be pumped at time of inspection) (lo e on site plan):
Depth below grade: • TIGHT TANK
Material of construction:
❑ concrete ❑ metal ❑ fiberglass El polyethylene y El other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
' c '-'\ Commonwealth of Massachusetts
Title 5 Official Inspection Form
-------,40,----= Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
' 4 Marsh Point,Yarmouth Port, MA
Property Address
Kathleen Fargo 4 Marsh Point
Owner Owner's Name
information is Yarmouth Port MA 02675 3/20/2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) -
1 8. Tight or Holding Tank (cont.)
Alarm present: ❑ Y-s El • o
Alarm level: Alar , orking order El Yes ❑ No
Date of last pumping: v i
II ate
Comments (condition of alarm and float swit •-s, etc.):
*Attach copy of current pumping contract (required). Is copy attached? El Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert AT INVERT
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
DBOX IS BREACHED, CRACKED OR CORRODED AND NEEDS TO BE REPLACED.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
-_y 'F Title 5 Official Inspection Form
, :., .7.-- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
3
4 Marsh Point, Yarmouth Port, MA
Property Address
Kathleen Fargo 4 Marsh Point
Owner Owner's Name
information is Yarmouth Port MA 02675 3/20/2020
required for every
page. City/Town State Zip Code Date of •_pection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑; Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, • itio of pum and appurtenances, etc.):
* If pumps or alarms are not in forking order,system is a conditional pass.
11. Soil Absorption System AS) (locate on site plan, excavation not required):
If SAS not located, e •lain why:
Type:
❑ leaching pits number:
® 3, FLOW leaching chambers number: DIFFUSORS
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number,dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
n Title 5 Official Inspection Form
®W = a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r 1= 4 Marsh Point,Yarmouth Port, MA
Property Address
Kathleen Fargo 4 Marsh Point
Owner Owner's Name
information is every Yarmouth Port
required for eve MA 02675 3/20/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
LIQUID LEVEL ABOVE INPUT AND OUTPUT OF FLOW DIFFUSORS, INDICATING HYDRAULIC
OVERLOAD AND LESS THAN 1/2 DAY'S CAPACITY. THIS IS A FALURE CRITERIA.
GRADE TO SAS TOP: 2.6'. SAS LIQUID LEVEL IS 12". STAINLINE 1"ABOVE LIQUID LEVEL.
GRADE TO SAS BOTTOM IS 4.1'. EFFECTIVE DEPTH: 1'.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site pla .
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, si. s of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
.
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
, •
4 Marsh Point, Yarmouth Port, MA
Property Address
Kathleen Fargo 4 Marsh Point
Owner Owner's Name
information is Yarmouth Port MA 02675 3/20/2020
required for every
page. City/Town State Zip Code Date of Insp., ion
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction: NOT APPLICAB
NOT APP CABLE
Dimensions
N• APPLICABLE
Depth of solids
Comments (note condition of soil, signs o ydraulic failure, level of ponding, condition of vegetation,
etc.):
NOT APPLICABLE
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
{
Commonwealth of Massachusetts
Title FA I
� � �►_ 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address
Owner Owner's Name
information is
required for every MA
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
►� hand-sketch in the area below
0 drawing attached separately
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kborA
of
O 2
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r,
Li It
tto
j12=2-x.51 blF (12. '
A3=SI f B3 - t
e 37-5'
t5insp.doc•rev.7/282018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
,
• "..N Commonwealth of Massachusetts
‘:‘,rf i( Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4 Marsh Point,Yarmouth Port, MA
Property Address
Kathleen Fargo 4 Marsh Point
Owner Owner's Name
information is
required for every Yarmouth Port MA 02675 3/20/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
Check Slope
' / Surface water
Check cellar
® Shallow wells
Estimated depth to high ground water: 8' BELOW GRADE
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
FROM REPAIR PERMIT APP. 1992
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
GROUNDWATER FOUND AT 8' BELOW GRADE ON 5/29/1992.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
s Title 5 Official Inspection Form
—Fw Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1113 l
4 Marsh Point, Yarmouth Port, MA
Property Address
Kathleen Fargo 4 Marsh Point
Owner Owner's Name
information is Yarmouth Port
squired for everyMA 02675 3/20/2020
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
4 A. Inspector Information: Complete all fields in this section.
It B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist)completed
® D. System Information:
For 8: Tight/Holding Tank–Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
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